Medication Carts Not Maintained in Clean and Sanitary Condition
Penalty
Summary
Surveyors observed that three out of four medication carts (located on Halls 300, 400, and 500) were not maintained in a clean and sanitary condition. The drawers of these carts contained crushed pills, loose pieces of paper, dust, and in some cases, whole or partial pills. These observations were made during walkthroughs with nursing staff, who acknowledged that the carts could have been cleaned better and stated that cleaning was typically assigned to the third shift, but any nurse could perform the task. Interviews with multiple nurses and the Director of Nursing confirmed that the responsibility for cleaning the medication carts was assigned to the third shift nursing staff, and this was consistent with the facility's Medication Storage policy. The failure to keep the medication carts clean and free of medication debris and other contaminants was directly observed and confirmed by staff, indicating non-compliance with requirements for proper storage and maintenance of drugs and biologicals.
Plan Of Correction
Element 1: Medication carts on 300, 400, and 500 halls were cleaned during survey. Element 2: Audit of medication carts was completed to ensure all medication carts are clean and sanitized, free of crushed pills, pieces of loose papers, and dust in the drawers. Any identified areas were addressed. Element 3: The Director of Nursing/Designee reeducated Licensed Nurses on cleaning of medication carts, which included making sure cart drawers are free of dust, paper particles, and crushed pill residue. Any Licensed Nurses not educated by May 20, 2025, will be educated on their next scheduled shift. Nurse managers/designee will complete random weekly audits of medication carts to ensure they are clean and sanitized. Element 4: Unit Manager/Designee will complete random weekly audits, for four weeks, of medication carts to ensure they are clean and sanitized. They will also query Nurses if they are able to verbalize the appropriate way to clean medication carts, with results reported to the Director of Nursing who will be present to QAPI for further follow-up and recommendations. Element 5: The Director of Nursing will be responsible for maintaining compliance.